NCS000346 DMR SW - Not On Required DMR Form

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pFull-Service Analytical &
= P -R I S M I Environmental Solutions
LABORATORIES ING
449 Springbrook Road • P.O. Box 240543 • Charlotte, NC 28224-0543
Phone: [phone] • Fax: [phone]
Client Company Name:
Report To/Contact Name: .t -c/ A
Reporting Address: / S/ O C
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Phone:'? 9 - yo 2" ;*fix?(Yes) (No):
Email (Yes) (No) Email Address
EDD Type: PDF_ Excel O her
Site Location Name:X m
Site LocatiQn Physical Address: 1!r16 Cen zzX
CHAIN OCUSTODY RECORD
= ONLY
TIME
COLLECTED
MILITARY
HOURS
'PAGE OF QUOTE F TO ENSURE PROPER BILLING: ` r `1 0 � Q
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Samples INTACT upon arrlval2„-
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�roject Name Q W
aRecelded;ON.WET ICE? Temp , 3_/.; ', ,. , - !'` • ; :' =
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PE
SEE BELOW
' ?ROPER,PRES�RVATIVESindfcated?, ;', '-'r'>"r '''' ''AZ
CD
Short Hold Analysis: (Yes) (No) UST Project: (Yes) No)
II
Received WITHIN HOLDING TIMES?,, - ✓1=
„ Please ATTACH any pjoject specific reporting (QC LEVEL 111 III IV)
. _ _Co
— -
provisions and/or OC a uirements
-` CUSTODY• EA1 NT ;"�."
Invoice To: �irL er U1v..c
'VOI:AT,IL'ES rec'd.Vy%OU rH�ApSPACE?,';CONTAINERS
used?Address:
,
Purchase Order No./Billing Reference M 8�
TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
Requested Due Date ❑ 1 Day ❑ 2 Days ❑ 3 Days ❑ 4 Days ❑ 5 Days
Certification: NELAC USACE FL NC
"Working Days” ❑ 6•Days ❑ Standard 10 days ❑ Rush
e h Wor Must Be
Samples received after 15:3t will be processed next business day.
SC_ OTHER N/A
Turnaround time is based oli business days, excluding weekends and holidays.
Water Chlorinated: YES NO
(SEE REVERSERTERMS
RENDERED BY PRISM
CONDITIONS SERVICES
LABORATORIES, IC. TO CLIENT)
_
Sample Iced Upon Collection: YES NO
CLIENT
SAMPLE DESCRIPTION
DATE
COLLECTED
TIME
COLLECTED
MILITARY
HOURS
MATRIX
(SOIL,
WATER OR
SLUDGE)
SAMPLE CONTAIgJER
I
PRESERVA-
TIVES
ANALYSES REQUESTED
�Yl
\ V 1 F� C/ f,L•
5 ^ .' i` \� J REMARKS
PRISr�
ID B
PE
SEE BELOW
NO.
SIZE
Upon relinquishing, this Chain of
submitted in writing to the Prism
Sampled By (Print Name)14 rill L L-) ) �I V-• J Affiliation , 2 a� c e 0.0
authorization for Prism to proceed with the analyses as requested above. Any changes must be
r. There will be charges for any changes Ofter analyses have been initialized.
nenncImneu ny: tbignaLure) Receive or Pnsm Labora�t°r�es By: Date 1
F� - 11'111!(1 (t)s
--- �------------... ------ -
SAMPLES ARE NOT ACCEPTED AND VERIFIED AOAIt� OC UNTIL RECEIVED AT THE LABO RY
TO, p ,,t
❑ Fed Ex ❑ UPS Ell -land -delivered ❑ Prism Fleld Service ❑ Other
NC ❑ SCI ❑❑ NC ❑ SCI GROUNDWATER: C0R:I
0D NICKI0 SC UNC
SOLID WASTE: ❑ NC ❑ SC ❑ NCA CLLANDFILL
Li SC E] NC❑ SC El NC ❑ SC C] NC El SC
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`CONTAINER TYPE CODES: A = Amber C =Clear G =Glass P =Plastic; TL = Teflon -Lined Cap VOA =Volatile Organics Analysis (Zero Head Space)
Additional Comments:
PRISM USE ONLY
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ORIGINAL